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Feeding and nutrition after brain injury A person recovering from traumatic brain injury (TBI) will require close monitoring of their nutritional status in the acute and rehabilitation phase of their injury. A dietitian is able to assess the nutritional status, management of nutritional care and education to patient and their family to ensure optimal nutrition and care is provided. Acute Phase Most people with brain injury are well nourished before the injury, however if nutritional intervention is not put in place immediately, they are susceptible to develop nutritional deficiencies. The stress of initial injuries also known as a hypercatabolic state and may persist for 4 – 6 weeks or be sustained throughout the injury. The importance of immediate nutrition care will decrease the change of rapid loss of nutritional stores, in particular protein, resulting in lean muscle loss and suppressed immune function. Such patients are susceptible to a decrease in physical and cognitive abilities that may lead to emotional and behavioural changes. These changes can affect their ability to have food orally resulting in gradual nutrition deterioration that could lead to starvation if not treated. If a person with TBI is not be able to swallow food, then nutrition support should be initiated by feeding liquid food through a feeding tube that is inserted through the nose and into the stomach (Nasogastric feeding). If a person has facial trauma and the nasal passage is not passable, then a tube through the mouth into the stomach (Orogastric feeding) will be inserted. If a feeding tube is required for more than 4 – 6 weeks, a tube may be inserted directly into the stomach known as a Percutaneous Endoscopic Gastrotomy (PEG) tube. This method allows for safer and more comfortable tube feeding. There are two common methods for feeding:  Continuous feeding: A liquid feeding formula that is delivered continuously from a feeding pump given at a slow rate over a period of 12 – 24 hours depending on a person’s tolerance to the feeding.


 Bolus feeding: A liquid feeding formula that is given regularly via a syringe at a 2 – 3 hour interval. Each feed is not more than 300ml volume each time inclusive of water flushes. The liquid foods selected for tube feeding are complete nutritional formulas that will meet a person’s total nutritional requirements. They are convenient, hygienic and well tolerated and are available in liquid or powder form. This can be obtained from pharmacies and selected powder formulas are also available in supermarkets. Do check with a dietitian on the formula that is tailored to the needs of a person.

(Source: “Learning About Tube Feeding At Home” Nutrition and Dietetics Department, Tan Tock Seng Hospital) The amount that a person will require will depend on a person’s calorie, protein, fluid, healing and weight requirements. Additional considerations to feeding requirements will be needed if a person has wounds, infections, other injuries, nutrient imbalance, and medical or rehabilitation problems. This can be determined by a dietitian who will manage the feeding and review accordingly. As their condition improves, nutritional assessment needs to be planned for the future, most often includes weight monitoring. If a person is underweight, gradual weight gain is preferred rather than rapid gain as this can lead to excessive deposits of fat stores. The care plan is a continual effort and reviewed with the person with TBI and their family before discharge from the acute or rehabilitation program. Rehabilitation phase Some people with TBI will require tube feeding for a long period of time. However, if a person with TBI is reviewed by a speech therapist and is safe to have oral feeding, they will be monitored closely for the adequacy of intake base on the food and fluid


consistency suitable and safe for swallowing. If a person’s oral intake is poor, then they will need to be supplemented with liquid formulas or to explore food habits and preferences to encourage a person to eat through consistency of food, presentation of food, and planning a balanced diet. The consistency of food should be safe for a person with TBI. The speech therapist will be able to determine the appropriate modified consistency of food (i.e. blended, soft and moist or easy chew) and fluids (i.e. pudding, honey, nectar or thin) of a person with TBI. Once the safe consistency of food is obtained, the food preparation and ingredients need to be chosen with care to ensure safe swallowing. A person with TBI will still have appreciation for well-presented and appetizing food when served. It is essential especially if the food is in a modified consistency. This is enhance through colour, variety of food and taste. It is also important that the meal served is adequate in nutrition. Planning a balanced diet is important to allow adequate nutrition for the recovery in a person with TBI. The table below will be a guide to choosing and planning meals from the four major food groups. Breads, cereals, rice,

Vegetables

Fruits

Meat & Alternatives

2 serves daily

2 serves daily

2 –3 serves daily

pasta and noodles 5 – 7 serves daily

1 serving = 2 slices bread 1 bowl macaroni 1 bowl porridge 1 bowl of oats

½ cup cooked vegetables

1 wedge papaya 1 medium banana 1 medium apple

1 palm size meat

1 cup cooked lentils 1 glass of milk

1 slice cheese


It should include complex carbohydrates such as breads, rice, cereals, pasta and noodles. The diet should also incorporate a generous amount of vegetables and fruits to provide vitamins and minerals. Proteins, iron, zinc, calcium and vitamin B12 are essential for wound healing, prevention of abnormal red blood cells, and osteoporosis or brittle bones. A person with TBI will benefit from a low fat diet to maintain ideal body weight range. Lean meat, low fat dairy products and legumes should be chosen. During food preparation, salt, oil, fat and sugar should be used in small amounts and taken occasionally. Alcohol should be avoided after brain injury as it lowers the seizure threshold.

When a person with TBI is not able eat adequately from a balanced diet due to a loss in taste, smell or poor appetite, some suggestions include providing small, frequent meals and snacks, serving food with stronger natural flavours to improve the appetite and including all foods from the food groups as above. This can influence the progress with rehabilitation. Oral formulas can also be supplemented with or between meals to ensure adequate nutrition is obtained. Do check with a dietitian for the most suitable oral formula if you are unsure.

Good nutrition is vital in the acute and rehabilitation phase in the management of people with brain injury. Malnutrition is correlated with an increase in medical complications, length of hospital stay and poorer functional outcome. A wellnourished individual will be able to weather the initial stress of injuries and recover better compared to a person who is malnourished.


Feeding and nutrition in brain injury-2006